Sanjeevani report 2009

SANJEEVANI A study on the efficacy of a theory driven HIV and public health response to migrant construction workers health and well being in the Delhi National Capital Region

R.K. Puram, New Delhi

TABLE OF CONTENTS

List of abbreviations List of tables List of figures Foreword Preface Acknowledgements Executive Summary 1. Introduction 2. Maitri: Organisational Background 3. Conceptualisation & Review of Literature 4. Methodology 5. The Needs Assessment and Baseline Survey 6. Project Intervention: Components and Strategies 7. Assessing the Impact: The Results 8. Discussion and Conclusion Annexure 1: References Annexure 2: Chronological list of events Annexure 3: Area Map Annexure 4: Glossary of slang and colloquial terms Annexure 5: List of IEC material utilized Annexure 6: List of key stakeholders Annexure 7: Sanjeevani Team

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LIST OF ABBREVIATIONS HIV AIDS STI STD TB DOTS MSM FSW CSW IDU VPL HC WAD PLHA IEC IDI FGD ICTC VCTC NGO RMP

Human Immune deficiency Virus Acquired Immune Deficiency Syndrome Sexually transmitted Infections Sexually Transmitted Disease Tuberculosis Directly Observation Treatment Short term course Men who have sex with men Female Sex Worker Commercial Sex Worker Injecting Drug Users Volunteer Peer Leader Health Camp World AIDS Day People Living with HIV AIDS Information, Education, Communication In Depth Interview Focus Group Discussion Integrated Center for Testing and Counseling Voluntary Center for Testing and Counseling Non Governmental Organization Registered Medical Practitioner

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LIST OF TABLES Table No. 4.1 6.1 7.1 7.2 7.3 7.4

Title Variables studied in Project Sanjeevani Levels of Influence Comparision of health status in the migratory destination as well as native place Knowledge and awareness with regard to HIV during needs assessment and impact assessment study Attitude towards PLHIV during needs assessment and impact assessment study Behaviour of workers in the context of sexual health and HIV

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LIST OF FIGURES Figure No. 1.1 4.1 4.2 4.3 5.1 5.2 5.1 6.2 6.3 6.4 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8

Title Primary Health Care flow chart with example City Map of Faridabad depicting project Area Sampling: Migrant male Construction Workers Sampling: Migrant Female Construction Workers One of the Colonies of construction workers on the site The Construction site BCC through street play The health camp Condom demonstration and distribution HIV testing by trained Maitri staff Health seeking behaviour Comparative data of HIV knowledge and awareness among male and female workers during baseline and endline survey No. of sexual partners of the respondents Condom Use Commercial Sexual Partners HIV testing Received Health related advice from any agency or official Social Participation

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FOREWORD In recent years, urban development has seen large sections of population moving from one part of the country to another in the hope of improving their economic prospects. Many attempts to survey population movement tend to omit the bulk of short-term movements between villages and cities that are extremely significant not only in India but throughout South-east Asia. This circulation of people forms complex networks of continuous contact between origins and destinations that can serve as conduits for the passage of money, of goods and ideas, and of disease. Migrants are susceptible to infectious diseases because of the very poor, crowded and unhygienic living conditions. They are rarely full citizens in their place of work. In the formal context, they lose voting rights, as well as free healthcare and subsidized food and fuel under the Public Distribution System. It becomes less easy for them to access free education for their children. They are often regarded as illegal residents and may be subject to police harassment. Migrant populations, such as long-distance truck drivers, commercial sex workers and migrant workers come in contact with local communities, including those providing informal and formal sexual services often under the guise of roadside restaurants, bars, barbershops and guesthouses.

Interaction among diverse sectors of mobile populations forming different patterns may intersect at certain points. It has been well documented that the behaviour and practice of the mobile populations and that of the stationary community population with which they come into contact together contribute to the acceleration of HIV in areas previously isolated from external contacts.

Omaxe Foundation has been witnessing closely the social, economic and political marginalization of the migrant construction workers with whom it works in various parts of North India. Despite the contribution made by migrants to the national economy, most remain on the margins of society, unable to influence their working and living conditions, and without political voice, especially where they migrate to other states. To respond to this challenge, Maitri and Omaxe Foundation initiated Project Sanjeevani, a Public Health Initiative for Migrant Construction Workers. Conscious efforts were made through this project to build a sustainable resource of information, and organizational and human networks within the community. This report aims to produce strategic recommendations for similar collaborations aimed at contributing to the health and well being of migrant populations in India and the South Asia Region.

Sushma Goel

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PREFACE Globally the number of people living with HIV/AIDS at the end of the year 2004 stood at 40 million, while the epidemic is estimated to have claimed more than 3 million lives the same year according to UNAIDS/WHO estimates. The statistics are raising grave concern since the infection is rapidly spilling over to the general population from those with high risk behaviour like commercial sex workers, truck drivers and migrants known to have vulnerability towards HIV. In India since the first reported case in 1986, HIV has taken the form of an epidemic and is also one of the leading causes of life threatening diseases such as tuberculosis, cancer, dementia and eventually death amongst the most productive and reproductive sections of the population.

The problem is aggravated by the fact that there is lack of overall awareness about the disease among majority of the masses. Continuing myths and misconceptions regarding the cause and transmission of the disease are causing people living with HIV/AIDS to be discriminated against by the society. It is also leading to ‘physicians’ bias which is posing a major deterrent to treatment and care of HIV infected people. Further, the stigma attached to certain high risk populations extends the marginalization of certain vulnerable populations.

Efforts are underway in almost all parts of the country to implement large scale information and education programmes for HIV/AIDS prevention. However, the increasing number of HIV infections suggested that there is an urgent need to scale up such interventions in terms of area as well as magnitude. The NACP III has stressed the importance of awareness generation through community involvement and participation. As a response to this urgent need, Project Sanjeevani was undertaken with a broad objective to create awareness about HIV/AIDS, STI and TB among migrants who are identified as not only marginalized but also among the most vulnerable to these infections. The sample for Sanjeevani comprised of migrant workers in the construction sector. Their vulnerability to HIV and other infections is further aggravated because of lack of awareness about diseases and general apathy. The specific objectives of the project were to have an insight into the socio-economic circumstances of the migrant construction workers, to develop a strong research base that would guide the interventions among the migrant construction workers, to generate awareness with regard to general health, HIV and STIs and work towards reducing stigma and discrimination. The main thrust of this project was to involve the community to ensure sustainability of efforts.

This project was carried out in three phases. The first phase was that of making an initial assessment of the knowledge level, types of attitudes, behaviour and practices of the target group with regard to HIV, STI and TB along with general health seeking behaviour. For this, regular visits were made to the construction site in Faridabad, approximately 35 kilometers from South Delhi. Information on the above mentioned areas was gathered with the help of in-depth interviews,

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questionnaires, focus group discussions and area mapping. This initial needs assessment took into account the working and living conditions of the construction workers, their behaviour and practices, along with identifying the factors of vulnerability towards HIV and other diseases.

In the second phase, identification and training of volunteer peer leaders (VPL), development of awareness generation modules, outreach activities as well as service provisioning was included. The interventions saw increasing participation from the community as well as increase in awareness levels. It was crucial for the outreach team that they should not be treated as a threat to the community’s value system. Keeping this in mind, right in the initial stages of phase one the Sanjeevani team had started building rapport with the construction workers’ community. This was an effort which took time and paid dividends in phase two.

In the third and final phase of the project, the impact of interventions and community participation was assessed using the same tools as were used in Phase I. A comparative analysis was done for specific variables to study the changes in knowledge, attitude, behaviour and practice of the construction workers as a result of the intervention. It is however crucial to mention here that one of the challenges faced was the fact that a substantial percentage of respondents who were part of the needs assessment survey were replaced by another batch of migrants during the course of the project. However, since this transition was gradual, the project continued to include new entrants on site into the intervention process, while also treating its outgoing target group as a knowledge resource trained and motivated to spread awareness wherever they would migrate.

The results portrayed a significant change brought about as a result of the interventions in the awareness levels of the migrants. As a sustainability plan for Sanjeevani’s efforts, networking with local faith based and non-governmental organisations as well as a trained team of VPLs were developed in order that they gain ownership of the programme when Sanjeevani graduates out.

Bhavana Gulati, Joe Thomas, Sonal Singh Wadhwa

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ACKNOWLEDGEMENTS Project Sanjeevani was an honest effort on the part of the Maitri team to bring about a difference in the lives of the migrant construction workers. Sanjeevani could be accomplished with support and guidance from a lot of people, whose efforts I sincerely want to acknowledge.

We want to start by thanking Dr. Smarajit Jana under whose guidance and encouragement the project was concretized.

We thank the Director General, Department of TB, Dr. Chauhan who extended his support by providing IEC material and put the Sanjeevani team in touch with the District TB Office in Faridabad. We are also grateful to the District TB Officer, Dr. Pahuja and his successor Dr. Pasricha, both of whom were very supportive of the programme and ensured the department’s participation in awareness generation as well as TB testing.

We express our gratitude to Dr. P.H. Mishra from the Indian Spinal Injuries Centre for supporting the Health Camps through doctors and also for providing medicines for the construction workers. We also thank all the doctors including Surgeon Commander Vikram Singh for responding effectively to the unexpectedly high demand during the health camps.

AIDS Healthcare Foundation (AHF) India Cares provided testing and treatment support for Sanjeevani. AHF India Cares also organized a Training of Trainers programme on HIV testing and couselling for the project staff. We are grateful to Dr. Chinkholal Thangsing, AHF Asia Pacific Bureau Chief for making this happen.

We are thankful to the Red Cross Society of Faridabad for sharing their findings about the high risk groups and bridge populations in Faridabad and for supporting Sanjeevani with IEC and preventive material.

The construction workers gave us some of their time everyday and made efforts to identify with the concerns that were presented before them. We are truly indebted that they not only allowed us to intrude into their private lives but also became part of this mission. The Senior Project Manager, OMAXE, Mr. Sanjay Goel, Project Manager, Mr. R.K. Singh, and the site incharges of Trishul, Vatika and Jaycon, Mr. P.K. Saluja, Mr. Atul Saxena and Mr. Rajiv Goel went beyond their very tightly scheduled plans to accommodate awareness workshops and meetings with their staff as well as workers. We also want to acknowledge the assistance of the supervisors and contractors in organizing events and motivating workers to participate. It was the motivational push from their own leadership that made the workers accept the values of the project. Among these, the Volunteer Peer Leaders who carried Maitri’s efforts forward and contributed proactively to Sanjeevani objectives deserve a special mention.

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We take this opportunity to also thank CII and Modicare for helping us develop an understanding of ground realities of migrants in the construction industry, while Sanjeevani was being conceptualized.

Mehek, the theatre group presented brilliant informative street plays as part of the IEC campaign. We thank the Mehek team.

Dr. Joe Thomas, the technical advisor of Maitri has guided this project in every possible manner right from its inception to its completion. The Sanjeevani team owes a lot of its learning and success to Dr. Joe Thomas. We cannot thank him enough.

Mr. Rajesh Mishra analysed the data and put together the tables and graphs, some of which have been used in this report. We thank him for all his efforts and his time.

Lastly, but most importantly, we would like to mention the efforts make by the outreach workers and the Sanjeevani research staff to make Sanjeevani not only acceptable to the construction workers, but a mission among them. We sincerely appreciate their hard work.

Winnie Singh

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EXECUTIVE SUMMARY The impact of migration of people on the spread of HIV/AIDS is both obvious and complex. While migrants represent a critical element as vectors for the spread of the disease, we also recognize the issue that migrants are a particularly vulnerable group. The NACP-III plan document recognized the focus needed on migrants. These migrants typically live in large cluster formations, around industries or cities, in slums, on construction sites. For months or years, the short duration migrants live far away from their families, working in factories, construction sites or striving to earn a living. Sometimes this makes them liable to practicing unsafe sex, and increases the risk of contracting STI or HIV. In India, the concerns with regard to bridge populations such as migrants are compounded by sheer numbers.

Project Sanjeevani was a step in response to the needs of the migrant workers as understood in various studies and pointed out in NACP III plan document. This report presents the experience of Sanjeevani, the research and intervention Public Health Project with a special focus on HIV/AIDS, STI and TB. The conceptual principles which guided this project are: Health equity, health promotion, primary health care, gender and social capital. The dynamics of these principles determine the efficacy of HIV and public health response to the migrant construction workers health needs.

Project Sanjeevani was initiated by conducting a baseline survey to assess the risks and HIV/AIDS vulnerability of the construction workers and to use that knowledge to develop the interventions. After implementing the interventions for four months, a survey was conducted to assess the impact. Both qualitative and quantitative methods were adopted in conducting the assessments. Mapping was also conducted in the area to identify the risks as well as resources. The survey was conducted using questionnaires developed by Maitri and stratified random samples were used for each of them. In depth interviews were conducted among timekeepers, supervisors and contractors to develop a stakeholders’ analysis.

Among the 1600 workers on the Omaxe Construction site, 323 were covered for the needs and risk assessment survey. However, this number reduced to 200 in the impact assessment survey, because a large number of workers had outmigrated from the site in search of better jobs in the face of economic recession.

Almost all the workers in the sample (99.7%) were migrants, about 1/3 of them living as single migrants who were more likely to have a high risk sexual behaviour.

The interventions focused on both men and women migrant construction workers.

A public health approach was adopted for the interventions, though strong emphasis was laid on creating awareness about HIV, STI and TB. Awareness generation was done through sensitization and awareness workshops, community meetings, mid media, IEC material and a peer educator programme. Service provisioning for healthcare was done by developing referral links with the local

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healthcare facilities and also organizing periodic health camps on the construction site.

The project had developed a sustainability plan – the peer educator programme – which was an integral component of the intervention. Apart from information dissemination, another important aspect of the project was service delivery. A critical marker which has emerged is the utilization of resources, largely local, by linking up with healthcare providers. Maitri adopted a three pronged approach in this regard: direct service provisioning; staff capacity building to provide additional services; networking with treatment providing agencies for general health as well as HIV and TB treatment. This model of intervention suggests that if HIV and TB are integrated into the public health delivery system, it increases uptake of services, leading towards health equity.

After four months of intervention, a survey to assess the impact was conducted.

The interventions were originally planned to last for a longer duration; however, as a result of the economic recession, the interventions had to be halted prematurely in order to be able to assess the impact. The impact assessment survey revealed that the interventions were successful in bringing about a statistically significant difference in the knowledge levels of the migrants about HIV. 82 per cent of the construction workers reported that they had gathered information with regard to HIV/AIDS from Maitri’s interventions during this project. The impact of the project interventions is also evident in the attitude of the workers towards HIV positive persons. Though this impact is statistically significant, it would have been possible to create a greater and more positive impact with longer duration of intervention. In terms of the sexual as well as health seeking behaviour of the workers, a statistically significant correlation had emerged. This includes variables like condom use, getting tested for HIV and willingness to know the results of HIV tests. However, not much difference was reported in the sex with non-regular partners. This can be explained by the fact that with such a short span of intervention, achieving significant and documental change in behaviour is a challenge. There is need for promoting risk reduction among this population through the use of condoms as well as by reducing the number of sexual partners.

The impact of the interventions on social connectedness and social participation among the workers has also been studied. While the workers had not reported receiving any health related advice prior to the interventions, 13% workers reported receiving health related advice from Maitri during the course of the project. Similarly, 18 % workers reported that they were ‘members of Maitri’ since they had participated in the interventions.

The interventions had also focused on Reproductive health of women along with HIV, STI and TB prevention. Among the women, negotiating condom use with the partner and familiarity of STIs showed a definite improvement because of the interventions.

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When asked about how the project benefited them, more than 50% of the workers reported increased awareness which led to an effort in changing their habits and behaviour.

We, therefore recognize that the project interventions have impacted certain aspects like awareness and attitude towards HIV positive persons, familiarity with STIs, condom use, and social participation more effectively than areas like reduction in multiple sexual partners which is a crucial aspect of risk reduction.

Interventions which would target the knowledge, attitude, behaviour and practices of the workers for a longer period of up to one year would have helped Maitri achieve a more holistic impact. However, this project demonstrated that a comprehensive public health approach with Primary healthcare components is acceptable and achieves the objectives successfully. Project Sanjeevani has been documented as a replicable model which will seek to supplement the national programme in having a measurable and positive impact on the lives of the migrant construction workers.

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1. INTRODUCTION India’s workforce comprises approximately 92 per cent in the unorganised sector.

This sector plays a vital role in terms of providing employment opportunities to a large segment of the working force in the country, and contributes to the national product significantly. In the rural areas, agricultural workers form the bulk of the unorganised sector. In urban India, contract and sub-contract as well as migratory agricultural labourers make up most of the unorganised labour force working largely in the manufacturing and construction industry. For the sake of improving opportunities and seeking work, people from the villages traditionally migrate to urban areas. Seasonal urban migration is also evident throughout India, where many migrants move into the city during periods of hardship and return to their native villages for events such as the harvest.

There are over 200 million migrants in India. A recent analysis of the Census 2001 data indicates that during 1991-2001, about 61 per cent migrants moved within the districts, 24 per cent within the states and 13 per cent inter-state.

Migrants can be classified into 3 broad categories: • In-country rural to urban or rural to rural migrants; • Trans-border migrants (those who move between India and the neighbouring countries); and • Overseas migrants.

1.1 Recognizing the need of the hour At the 1994 International Conference on Population and Development (ICPD) in Cairo, 179 countries agreed that population and development are inextricably linked, and that meeting people's needs for education and health, including reproductive health and empowering women are necessary for both individual advancement and balanced development. The conference adopted a 20-year Programme of Action, which focused on individuals' needs and rights, rather than on achieving demographic targets. Concrete goals of the ICPD centered among others on reducing infant, child and maternal mortality; and ensuring universal access by 2015 to reproductive health care, including family planning, assisted childbirth and prevention of sexually transmitted infections including HIV/AIDS. National governments were urged to adopt strategies that seek to develop rural areas by making or encouraging investments for increased rural productivity. In case of populations displaced due to migration, it further called for “measures to ensure that internally displaced persons received basic education, employment opportunities, vocational training and basic health-care services, including reproductive health services and family planning. Measures should also be taken, at the national level with international cooperation, as appropriate, in accordance with the Charter of the United Nations, to find lasting solutions to questions related to internally displaced persons” (UNFPA, 1995)

Seasonal and circular (also known as cyclical, oscillatory) migration, has long been part of the livelihood portfolio of poor people across India ( Rao, 1994, de Haan 2002, Srivastava and Ali, 1981). It is now recognised that migration is a part of the normal livelihood strategy of the poor (Mc Dowell and De Haan, 1997) and does not occur only during times of emergency or distress. Although panel data on seasonal migration in India are lacking, a growing number of microstudies have established that seasonal migration for employment is growing both in terms of absolute numbers but also in relation to the size of the working population as a whole (Breman, 1985; Breman, 1996; Rao, 1994; Rogaly et al, 2001). The National Commission on Rural Labour (NCRL) puts the number of circular migrants in rural areas alone at around 10 million (including roughly 4.5 million inter-State migrants and 6 million intra-State migrants). Large numbers of seasonal migrants work in urban informal manufacturing, construction, services or transport sectors, employed as casual labourers, head-loaders, rickshaw pullers and hawkers (Dev, 2002). Policy-makers have tended to perceive migration largely as a problem, posing a threat to social and economic stability and have therefore tried to control it, rather than viewing it as an important livelihood option for the poor. There is little by way of organized accessible support for poor migrants who face insecurity in their source location as well as destination.

As a response to the recommendations of the ICPD, governments focused on specific vulnerabilities of the migrant populations.

1.2 Migrants: The Vulnerable Group To support their families migrant workers leave their communities and social networks to work in other parts of the country where they often do not understand the language, do not know how to approach services and often have no access to them, where they form new communities, among others to deal with their need for warmth and sexual needs. It makes them vulnerable for HIV-infection. The 12 million temporary, short duration migrants are of special significance to the HIV/AIDS epidemic because of their frequent movement between source and destination areas. The impact of the migration of people on the spread of HIV/AIDS is both obvious and complex. Although AIDS was first reported only as recently as 1981, a voluminous literature already exists on the disease itself and on its relationship with migration. While migrants represent a critical element as vectors for the spread of the disease, we also recognize the issue that migrants are a particularly vulnerable group. We need to examine their vulnerability not only from the public health policy point of view, but also from that of human rights.

The NACP-III plan document recognized the focus needed on short term migrants. These migrants typically live in large cluster formations, around industries or cities in unauthorised slums. For months or years, the short duration migrants live far away from their families, working in factories, construction sites

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or striving to earn a living. Sometimes this makes them liable to practicing unsafe sex, and increases the risk of contracting STI or HIV. In the existing pattern of concentrated epidemics with pockets of high prevalence, movement of people in the absence of migrant friendly services can result in the rapid spread of the infection. It was planned under the NACP III that Factory owners, construction companies and other employers engaging the services of these migrants would be motivated to undertake preventive education activities among them. In India, the concerns with regard to bridge populations such as migrants are compounded by sheer numbers. Once the migrants reach their destination, barriers of language and other adjustment issues strengthen a sense of loneliness and could lead to possible risky sexual activity. Limited awareness of HIV/AIDS issues and lack of access to social support networks add to the migrants’ vulnerability (NACO 2006).

1.3 Significance of the Project Based on the experiences of NACP II, the NACP III Plan document suggested that active volunteers among migrants be identified, trained and encouraged to disseminate preventive messages among their fellow workers. Project Sanjeevani was a step in response to the needs of the migrant workers as understood in various studies and pointed out in NACP III plan document. It is noteworthy that not all construction workers are covered under the migrant workers component of the national programme. The focus of the national programme is on single migrants who stay away from their families. The vulnerability of the male migrants’ families and that of the women construction workers is not addressed sufficiently.

The objectives of Project Sanjeevani are in line with the Global as well as national AIDS strategy of creating an enabling environment and addressing issues related to vulnerability. While most countries of the world have developed strategic frameworks for effective HIV prevention, yet only a fraction of people at risk of the infection have access to basic prevention services (UNAIDS, 2003).

Thus, there is an urgent need to reach the most vulnerable populations with a comprehensive package of HIV prevention and health promotion. In this project efforts have been made to reach one such community of migrant construction workers, identified as having an increasing vulnerability to HIV/AIDS and other infections. Sanjeevani makes an attempt at documenting not only these vulnerabilities, but also any change in their awareness, attitude or behaviour which would prove crucial for prevention of HIV/AIDS, STI and TB. Further, Project Sanjeevani also demonstrates how community participation can be effectively used in raising health related awareness as well as in achieving sustainability of the programme with the help of trained Volunteer Peer Leaders (VPL).

1.4 Objectives of the Project

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Broadly, the project aimed at generating HIV and general health related awareness among the migrant construction workers as well as improving their health seeking behaviour.

The specific objectives of the project are as follows:  To understand the social, economic, ecological and psychological circumstances of the migrant construction workers, which make them vulnerable towards illnesses in general and HIV/STIs in particular.  To develop a strong research base that would guide the interventions among our target community.  To generate awareness with regard to general health, HIV and STIs and work towards reducing stigma and discrimination.  To aim at improving the health status and the health seeking behaviour of the target community.  To create a replicable intervention model which could supplement the national programme.

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2. MAITRI- ORGANISATIONAL BACKGROUND Through its past initiatives, Maitri has developed an understanding of migrant issues and gathered a rich experience of working with migrants in the uniformed services. Maitri has also been working very closely with the slum communities to address their basic necessities of health, education, income-generation and empowerment. Health camps have been organized to provide testing and treatment facilities to the target communities. With regard to Sanjeevani, Maitri’s experience added value to both the components of the project.

2.1 Understanding of the needs Because of its past experience of working with marginalized and vulnerable communities, Maitri has developed a clear understanding of the needs that should be addressed. This has happened because Maitri has based its interventions on research and worked with a Needs-based approach. Likewise, in Project Sanjeevani, an initial needs assessment survey and stakeholders’ analysis was done which fed into the interventions. Also, having worked on General health and HIV/AIDS, Maitri is sensitive and responsive to the issues and needs of people.

2.2 Good Network and Advocacy Maitri has been working in collaboration with various stakeholders at the local, regional and national level. This has led to the formation of an excellent network with the community-based, government, private, non-governmental, bilateral as well as multilateral agencies. It has also enabled Maitri to advocate strongly on issues which have been a focus of their interventions.

2.3 Staff Maitri has a dedicated and experienced core staff, and Advisory as well as Executive boards which comprise of people who bring along with them a rich experience of health and developmental issues. Apart from this, recognizing the fact that Project Sanjeevani would require a long-term dedicated focus, experienced Project staff was recruited.

2.4 Partnerships The inception of Sanjeevani was the result of a partnership between two like minded organizations aiming at bringing about a positive change in the lives of marginalized communities. Maitri and Omaxe foundation came together to join their strengths for the welfare of the Migrant construction workers. Maitri also forged a partnership with AHF India Cares, who supported the voluntary HIV testing and treatment of the target population. Similarly, the RNTCP provided technical support by arranging for on site sample collection for sputum examination for TB. These partnerships mean also that it increases the ownership of the

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programme and safeguards the interests of the target community at different levels.

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3. CONCEPTUALISATION AND REVIEW OF LITERATURE Sanjeevani is a Public Health project with a special focus on HIV/AIDS, STIs and TB. It has been conceptualized keeping in view five important components to guide the objectives of the project. The components are:     

Health Equity Health Promotion Primary Health Care Gender Social Capital

This section presents an understanding of each of these components. These cover the entire gamut of the social, political, economic and ecological determinants which have an impact on the lives of people. It is of even greater relevance when the population in question struggles to meet basic needs, has little no so social security because of falling into the ‘informal’ or ‘unorganized’ sector, and has limited awareness of issues significant to their health and well being. Adding to this, the constant mobility of the migrant construction workers and their families renders them vulnerable to a range of illnesses and health problems.

3.1 Health Equity Health equity is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage or disadvantage in terms of socio-economic status. People who are already socially disadvantaged by virtue of being poor, women, or members of particular minority cultural or ethnic groups are pushed into further disadvantage with respect to their health (Braveman & Gruskin 2003).

Inequalities between the poor and the better-off persist. The poor tend to suffer higher rates of mortality and morbidity than do the better-off. They often use health services less, despite having higher levels of need as a result of their lack of awareness and the lack of other basic services like sanitation, hygiene, nutrition etc. And, notwithstanding their lower levels of utilization, the poor often spend more on health care as a share of income than the better-off. Indeed, some non-poor households may be made poor precisely because of health shocks that necessitate out-of-pocket spending on health. It has been recognized that these inequalities reflect mainly differences in constraints between the poor and the better-off—lower incomes, higher time costs, less access to health insurance, living conditions that are more likely to encourage the spread of disease, and so on—rather than differences in preferences (Alleyne et al.)

From the point of view of the working population, James Tobin (1970) and Amartya Sen (2002) have argued that health and health care are integral to people’s capability to function and their ability to flourish as human beings. As

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Sen puts it, “Health is among the most important conditions of human life and a critically significant constituent of human capabilities which we have reason to value” (Sen 2002).

“The failure of top down government efforts and the work of international bodies have led to the emergence of people centered health initiatives” These initiatives are often the result of partnerships made between private and public sectors or between non-governmental organizations and private groups. These partnerships can be defined as a “means to bring together a set of actors for the common goal of improving the health of a population through mutually agreed roles and principles” (Asante & Anthony, 2007) OMAXE and Maitri came together with a similar vision of jointly improving the Health of the migrant construction workers. The project’s objectives are to improve healthcare and create a template for future endeavors of this nature, improve sustainable impact by utilizing peer educators, work with the vulnerable population of migrant workers and advocate for social equity among this group of construction workers and their families. Migrant workers are vulnerable to contracting and transmitting diseases such as tuberculosis and HIV/AIDS. They often lack access to hygiene and sanitation, to healthcare and information regarding consequences of risky behaviors. As a result of the lack knowledge and their mobility away from their homes for long periods of time, they are likely to engage in unsafe behaviours such as unprotected sex and drug use. These actions often result in the contraction of STIs / HIV. Further, lack of awareness means that the disease is rapidly transmitted to their spouses and families. With the negative stigma that is attached to HIV, initiatives to combat this escalating problem need to be needs based. Project Sanjeevani faced many challenges with regard to health equity including successful delivery of health care, determining a standardized approach to health equity and support from community members.

3.2 Health Promotion Health promotion is the process of enabling people to exert control over the determinants of health and thereby improve their health. As a concept and set of practical strategies it remains an essential guide in addressing the major health challenges faced largely by developing nations, including communicable and non-communicable diseases, and issues related to human development and health. Health promotion is a process directed towards enabling people to take action. Thus, health promotion is not something that is done on or to people; it is done by, with and for people either as individuals or as groups. The purpose is to strengthen the skills and capabilities of individuals to take action and the capacity of groups or communities to act collectively to exert control over the determinants of health and achieve positive change.

Relevance of health promotion

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In tackling the determinants of health, health promotion includes combinations of the strategies first described in the Ottawa charter, namely developing personal skills, strengthening community action, and creating supportive environments for health, backed by healthy public policy (The first International Conference on Health promotion, Ottawa, 1986) Special attention is also given to the need to reorient health services towards health promotion. Thus, health promotion includes actions directed at both the determinants of health that are outside the immediate control of individuals, including social, economic and environmental conditions, and the determinants within the more immediate control of individuals, including individual health behaviours. Health promotion is a powerfully relevant strategy for social development - in particular as an important set of strategies to address the factors influencing inequalities in health. Health promotion also encompasses the principles that underlie a series of strategies that seek to foster conditions that allow populations to be healthy and to make healthy choices.

Health promotion and determinants of health Health is a resource for life that enables people to lead individually, socially and economically productive lives. It is a positive concept emphasizing social and personal resources (physical, mental and spiritual). It has long been acknowledged that there are certain prerequisites for health that include peace, adequate economic resources (and their equitable distribution), food and shelter, clean water, a stable ecosystem, sustainable resource use, and access to basic human rights. The challenge to meet these fundamental needs must remain a core goal for all action directed towards health, social and economic development. Recognition of these prerequisites highlights the inextricable links between social and economic conditions, structural changes, the physical environment, individual lifestyles and health. These links provide the key to a holistic understanding of health, and are meaningful to people's lives as they experience them. There are obvious inherent challenges in achieving the goal of reduced inequities. The United Nations Report on Human Development (2007/2008) suggests that efforts to reduce relative poverty, and to increase opportunities in education, employment, wages and participation in political and economic spheres are the key strategies for reducing inequities and, therefore, improving the health and wellbeing of those who live here (UNDP, 2007).

Challenges for health promotion Health promotion refers to a collection of strategies that can be applied to many health and development issues. This means that these strategies must operate within the context of issues like 'empowerment', 'advocacy', 'communications', 'education', 'social mobilisation', 'community participation', These components of health promotion are not ends in themselves, but are means to achieve healthier and fuller lives.

Since its inception, Maitri has worked with government, media, and industry, in an effort to promote access to health for those who live without it. Maitri’s health

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promotion activities aim to reduce differences in health status and ensure equal opportunities and resources to enable people to achieve their fullest health potential. In Project Sanjeevani, Maitri teamed up with Omaxe to expand the breadth of its health promotion activity.

Good health requires a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People must know how to make good health decisions, and where to turn in the event of illness. During this project, health education was provided to roughly 1600 workers and their family members at an OMAXE construction site in Faridabad, 35 kilometers from Delhi. Maitri established the health needs of the workers through a needs assessment survey which formed the basis of guiding the interventions of the project. The interventions covered information on HIV/AIDS and tuberculosis prevention, voluntary testing and treatment of TB, HIV and AIDS as well as addressing healthcare needs of the workers by organising health camps.

3.3 Primary Health Care "Primary Health Care is the essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination" (International Conference on Primary Health Care, 1978) The Essential Components of Primary Health Care include the principles of: 3.3.1 Equitable distribution: Health services must be shared equally by all people irrespective of their ability to pay and all (rich or poor, urban or rural) must have access to health services.

Primary health care aims to address the current imbalance in health care by shifting the centre of gravity from cities where a majority of the health budget is spent to rural areas where a majority of people live in most countries.

3.3.2 Community participation There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services, beside maximum reliance on local resources such as manpower, money and materials.

3.3.3 Intersectoral coordination Primary Health Care involves in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, food, industry, education, housing, public works, communication and other sectors.

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Project Sanjeevani has addressed Primary Health Care among the migrant construction workers, providing education and awareness on general health, prevention, care and support for TB and HIV. The success of the primary healthcare aspect and its referral system is contingent upon meeting the objectives of the project and needs of the construction workers and their families (Figure).

Sanjeevani Primary Health Care Objective s

Verificatio n o… f

Constructio ’ need n Worker s s

Primary Health Care Flow Chart Example

Formulat e Executio n Elements pitfalls (Identify etc.)

Protocol: Construction Worker Involvemen t 1 Educatio . n 2 Facilitate healthcare . delivery, testing , and

IImplementatio n

Manageme n

Resource s (equipment, referrals referrals, medical personnel

t

treatment Test results Referral s

3 .

4 .

Sensitization Training of Omax medical e personne

l

Result s

Validatio n

Figure 1.1 Primary Health Care flow chart with example elements

3.4 Gender Women’s identity is created within the framework of culturally constructed definitions of womanhood. They are considered the weaker sex and are forced to accept their inferior position in the society and to conform to their devalued selfimage. It is this image that defines the power-relations within the family. It is expected of them to defer their needs in favour of the needs of the family, especially where there are limited resources. Further, in most societies of the world, the physical survival and well being of the household is entirely the responsibility of the women. Through generations, societies have thrust upon women the roles of production and reproduction, and an inability to fulfill either of them ‘appropriately’ results in a further decline of their position within the family

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and the society. Additionally, to improve the financial conditions of the family and to shield the family from destitution, they take up waged work. The physical and mental rigors of the various roles assumed by the women weigh down heavily upon them. As earning members and household workers, women perform the vital role of caretakers and are responsible for all the work that is required to sustain the household. The lopsided variance of health as it stands against women appears to be set in stone( Gulati 2004).

The socially and economically disadvantaged groups, who need food, nutrition, drinking water and sanitation services most, are the ones deprived of them.

Women’s health is a product of these multifarious factors. The social and economic circumstances of women’s lives have an impact on their health. The dual burden of work borne by women together with their low social status predisposes them to poor health conditions. Economic deprivation means lack of adequate food, and having to pay for health care leads to further marginalization in terms of health and well being.

Further, the impact of HIV/AIDS specifically on women and girls is well documented. Along with feminisation of poverty, women now also face feminisation of the ill-health, specifically HIV/AIDS. HIV programming must take gender into account because of the social implications that women and girls face as a result of the common stigma that is attached with the disease. Provided below are some global statistics to demonstrate the necessity of gender considerations when conducting HIV and health workshops: • • •

In 1997, 4/10 people living with HIV/AIDS worldwide were women. By 2004, women made up almost 50% of people living with HIV/AIDS. In countries where heterosexual transmission is the main mode of HIV transmission, women are more likely than men to be infected with HIV. The highest ‘gender gap’ in HIV infection rates is recorded between young women and men between 15-24 years old (UNAIDS 2005)

3.5 Social Capital Social Capital refers to those features of social relationships - such as interpersonal trust, norms of reciprocity, and membership of civic organizations which act as resources for individuals and facilitate collective action for mutual benefit. Social capital has been applied in a variety of contexts to explain the ability of communities to solve the problems of collective action, ranging from the provision of public education, to the maintenance of effective and smoothfunctioning government institutions, as well as the exercise of informal control over criminal behavior (Sampson et al. 1997). The concept of social capital has been recently extended to the field of health to explain geographic variations in mortality and morbidity. At the community level, social capital is believed to promote health via stress-buffering and the provision of social support through

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extra-familial networks, as well as informal social control over deviant health behaviors such as underage smoking and alcohol abuse. At higher levels of social organization, e.g., states and nations, social capital may enhance health through indirect pathways, such as encouraging more egalitarian patterns of political participation that in turn ensure provision of adequate health care, income support for the poor, and other social services.

Despite the growing acknowledgement of the relationship between limited resources and poor health outcomes, we know far less about how to challenge and change health inequalities (Exworthy et al. 2000). At both national and international level much effort is being made to develop an evidence base about what works to reduce health inequalities (IUHPE, 2000). Notions of participation and promotion of civic life in policy development and implementation have stimulated debate among academics, policy makers and practitioners about the potential contribution of social capital in reducing health inequalities. The concept of social capital and the potential it offers for using community and civic pathways to promote and improve health has been promoted by some as one means of tackling inequalities in health (Gillies, 1998). The main indicators of social capital tend to include:  Social relationships and social support  Formal and informal social networks  Group memberships  Community and civic engagement  Norms and values  Reciprocal activities (e.g. childcare arrangements)  Levels of trust in others.

3.5.1 Social Capital in Project Sanjeevani Recognising the significance of social capital, Project Sanjeevani utilized the community networks for benefiting the community of migrant workers. The effectiveness and success of the project depends on the trust, networks and norms that are created within the community, and each sub-community. Maitri’s interventions aimed at building and strengthening networks among workers. As networks strengthened, workers began to share common values and vision. As the general health and productivity of the community improves, it has a positive impact on the overall happiness and well-being of the construction workers and their families.

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4. METHODOLOGY In the preceding chapters, we developed a perspective on the migrant construction workers in India and understanding of the conceptual components which guided this project. Based on the conceptualization, the methodology for the project was formulated.

4.1 The Area and population Project Sanjeevani was implemented among construction workers at the Omaxe Construction site, ‘Omaxe Heights’ at Tigaon road in Neharpar, old Faridabad.

The construction site is 35 kilometers from South Delhi. Omaxe and Maitri had joined hands for implementing Project Sanjeevani on some of Omaxe construction sites in North India. The Faridabad construction site was selected for the first leg of the project because it had a large number of workers approximately 1000 men, 600 women and 350 children - staying on the site, with.

Figure 4.1 City Map of Faridabad depicting the Project Area 4.2 Sampling

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A stratified random sample was used for the needs assessment as well as the impact assessment survey. The construction site was divided into three areas which were each being constructed and managed by different contracting companies. These were Vatika, Trishul and Jaycon. At the first level, the sample was stratified by the three contracting companies. At the second level, the stratification was that of men and women in each of these companies. At the third level, among men, the stratification was – Married heads of the household and Young men. Men below the age of 25 years were taken into the category of young men. Please refer to the figures below.

Married head

JAYCON VATIKA

MEN

TRISHUL

Young men Married head Young men Married head Young men

Figure 4.2 Sampling – Migrant Male Construction Workers

JAYCON WOMEN

VATIKA TRISHUL

Figure 4.3 Sampling- Migrant Female Construction Workers

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Apart from the migrant workers themselves, other key stakeholders also formed the sample of the study. These included Omaxe Project managers on the site, Contractors, timekeepers, tea-stall and canteen owners and security personnel on the site. In-depth Interviews and Focused Group Discussions were conducted with them to support/validate the data gathered from the workers.

4.3 Sample Size The sample size for the needs assessment was 20 per cent of the universe, which is 323. However, the sample size for the impact assessment could not remain the same, because of reduced number of workers on the construction site towards the end of the project. Since construction workers are migrants, they keep moving between the source and destinations periodically and also from one site to the other. They are known to spend anywhere between 3 months to one year on a site and then either go back to their villages for a few months or move to a new construction site. A project focusing on awareness generation through community participation lays a considerable amount of emphasis on the availability of community members over a long period of time. Repeated interaction with them during the initial survey, interventions and impact assessment surveys helps in judging the efficacy of the interventions. The challenge faced by Project Sanjeevani, therefore was to maintain continuous contact with the same community members over a period of 6 months or more.

Additionally, the economic recession led to a lot of construction workers out migrating in search of better remunerative options. As a direct impact the sample size in the impact assessment survey reduced to 200 from 323 in the needs assessment survey. Therefore, the data collected has only internal validity.

Additional data would be required for providing global validity.

4.4 Variables The variables were selected keeping in mind the objectives of the project. The variables for data collection were clustered under 8 heads. They are listed out as follows: Table 4.1 Variables studied in Project Sanjeevani CLUSTER

VARIABLES

1. General Demographic Information 1. Age 2. Sex 3. Marital status 4. Education 5. Caste 6. Religion

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7. Individual income 2. Family Information 1. Nature of migrant – single/with family 2. Family SIze 3. No. earning family members 4. Family income 3. Living Conditions 1. Duration of migration 2. Pattern of Migration 3. Reasons for Migration 4. Availability of resources( water/electricity/house) 4. Workplace & Working conditions.

1. No. of months per year spent on the construction site 2. Provision for Social support services 5. General Health and HIV/AIDS (KABP) 1. Health seeking Behavior 2. Current health status 3. Intoxication 4. Knowledge of HIV-AIDS 5. Attitude 6. Behaviour 7. Practice 8. Present HIV state ( positive or negative / not tested) 6.Social capital 1. Attitude toward self 2. Membership of association or organisation 3. Social participation 7. Women’s health (RTIs/STIs/Reproductive health) 1. Reproductive health 2. Violence or harassment at workplace 3. HIV testing during pregnancy 4. Familiarity with STIs 5. Communication with spouse 9. Benefits from the project 30

1. Respondent’s participation in project activities 2. Benefit from the project a) Increase in knowledge b) Change in Attitude c) Change in practices d) Change in behavior e) Tests & counseling 3. Information dissemination by respondent.

4.5 Tools and Method of data collection 4.5.1 Quantitative tools Questionnaire Questionnaires were used for gathering quantitative data from the migrant construction workers, both men and women. For the needs assessment, questionnaires were conducted with 320 workers – 200 men and 120 women.

The questionnaires were field tested for reliability and validity and accordingly modified before starting the needs assessment survey. For the impact assessment survey, questionnaires were conducted with 200 workers - 134 males and 66 females.

4.5.2 Qualitative tools In-depth Interviews In-depth interviews were utilized for gathering qualitative data from the workers as well as other stakeholders like supervisors, timekeepers, security personnel and dhaba owners on the site. Separate guides were developed to gather data from all the above mentioned categories of respondents. While workers were interviewed to explore issues of significance to their own socio-economic circumstances, vulnerability, risk factors and health and well-being, other stakeholders were interviewed to gain their understanding of the workers’ working and living patterns and also habits and behaviours that might predispose them to the risk of infections like HIV or STIs. Additionally, information was sought on the knowledge, attitude, behaviour and practice (KABP) with regard to HIV, STI and TB. A total of 49 IDIs were conducted during the needs assessment study with male and female workers, supervisors, timekeepers, security personnel and dhaba owners. During the impact assessment survey, 20 interviews were conducted.

Focused Group Discussion Along with In-depth interviews, Focused Group Discussions were conducted with stakeholders in all categories. Each FGD had about 8-10 participants. One FGD each would be conducted with the following groups: o Married male heads of the households

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o Young men (below the age of 25) o Women o Other stakeholders (Supervisors, timekeepers, site-in-charge, official physician) Area Mapping One of the main objectives of the project was to develop strong referral networks, which would lend sustainability to the efforts of the project. Area mapping is an important tool for meeting this objective. Area mapping required the field staff to go around the area on a number of occasions to prepare a map of the area and mark out significant features and details. Area Mapping was done with two objectives: 1. To identify the risk factors to the workers (liquor shops, sex workers’ cruising sites, panwallahs, sources of drugs etc) 2. To identify and network with agencies and resources which could support this initiative at the site (RMPs, traditional healers, barbers, grocery stores, NGOs, Religious organizations etc)

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5. THE NEEDS ASSESSMENT AND BASELINE SURVEY The needs assessment survey was conducted to develop an understanding of the socio-economic, ecological and psychological circumstances of the migrant construction workers as well as to assess the impact these are likely to have on their vulnerability to HIV and other illnesses. As part of the survey, questionnaires were administered to 203 male and 120 female workers. Additionally, 49 in-depth interviews were conducted with the workers as well as other significant stakeholders including supervisors, timekeepers, security personnel and dhaba owners on the site. We present below a brief understanding of the workers’ circumstances and their health.

5.1 A Demographic and Social Profile of the Workers Most of the respondents, both male and female included in the study are in the age group of 15-40yrs (almost 95%). Most of the women (85%), and men (70.4%) were married. 80% of the women and 45% men interviewed were illiterate. 48% of the respondents had up to 3 members in the family, followed by 4-6 members (39%), close to 10% respondents had a family size 7-10 members.

More than three fourths (75%) of respondents reported of l-2 earning members in the family, while close to one fifth said that there are 3-4 earning members in the family. Only 5% reported more than 5 earning members in the family.

More than 55 per cent of migrant workers in the sample belong to the state of Chattisgarh and more than 44 per cent of all respondents belong to district Bilaspur in Chattisgarh. Apart from 2.5 per cent of the respondents who speak Bengali or Oriya, the remaining 97.5 per cent respondents speak either Hindi or other dialects of Hindi, such as Bhojpuri, Bihari, Figure 5.1 One of the colonies of construction workers on the site Chattisgarhi, Bundelkhandi etc. 92 per cent of the respondents were Hindu, while a little over 7 per cent were Muslim. Less than 1 per cent respondents identified themselves as tribal.

39 per cent respondents were able to earn Rs. 2000 to 3000 per month and a similar per cent of workers earned more than Rs. 3000 per month. A little over 1 per cent respondents earned less than even Rs. 1000 in a year. 16 per cent of

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the respondents had a family income of less than Rs. 3000 per month. In terms of family income, 57 per cent families had a total income more than Rs. 4000 per month, 25 per cent of them had a family income of Rs. 3000 to 4000.

A little over 68 per cent of the respondents had migrated along with their families, while 31 per cent respondents migrated without families. Among those who migrated with their families, nearly 50 per cent are women, while the 31 per cent who are single migrants are all men. More than 61 per cent of the migrants reported that they were contacted by the sub-contractor who facilitated their migration to and employment at the construction site. 20 per cent migrated to this site because their relatives and friends were already employed here and promised to get them employment. 17 per cent respondents migrated on their own to search for employment. Nearly 68 per cent respondents cited dearth of basic resources and needs as the reason for migrating.

5.2 Working Conditions 28 per cent of the respondents work on the construction site throughout the year, while 37 per cent of them work for up to 9 months in a year on the site. 26 per cent of the respondents work for only up to 6 months on the site.

Over 62 per cent of them are provided with an accommodation of mud and brick walls with a tin roof, while 33 per cent have been provided a small tin structure as accommodation. 61 per cent of the workers have an electricity connection and 93 per cent have access to potable water; however, 64 per cent respondents reported Figure 5.2 The Construction site absence of sanitary facilities on the site, which required them to go outside the site in nearby agricultural areas to relieve themselves. In terms of social support benefits, 79 per cent reported provision for a school for their children on the site; less than 50 per cent reported provision of medical support at the time of accidents or medical emergencies. Only about 68 per cent of the respondents were provided safety measures like helmets, boots, soldering glasses etc. For accidents occurring on the site, 23 per cent respondents reported receiving monetary compensation by their contracting company.

5.3 General Health and HIV

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In the event of an illness, 78 per cent of the respondents consulted a doctor; the remaining reported that they either did not fall ill at all or treated themselves with home remedies. Among those who consulted the doctor, more than 65 per cent preferred to go to the private practitioner, 16 per cent to the government hospital and 3 per cent consulted the unqualified medical practitioners. 48 per cent respondents felt that their health was better in the village than in the city; while 44 per cent felt there was no difference in their health after migration.

Nearly 46 per cent respondents, both men and women, were in the habit of consuming tobacco. Nearly 20 per cent workers smoked. Only a little over 2 per cent respondents reported taking drugs like marijuana, smack, opium or brown sugar. Only one respondent reported that he had experimented with injecting drugs. 23.5 per cent of the respondents felt that intoxication increased the desire for sex and more than 5 per cent reported having had sex when they were intoxicated.

With regard to knowledge about HIV, nearly 47 per cent respondents have heard about HIV/AIDS, more than 70 per cent respondents on an average have no knowledge about the source and means of spread of HIV/AIDS and means of prevention. Most of those who had heard about HIV, did so either on TV, radio or from a friend or co-worker. 5 per cent respondents reported multiple sexual partners, while more than 88 per cent said they had never used condoms. Only three workers reported having sex with a sex worker and they did not use condoms.

Only 2 respondents reported having done an HIV test. The remaining 98 per cent had never done an HIV test. However, more than 90 per cent reported that given an opportunity, they were willing to get themselves tested for HIV. If found positive nearly 45 per cent of them would prefer to seek treatment in a government hospital. “For a long drawn treatment, we would need to see that the expenses do not eat into the basic necessities of other family members, our resources are limited to just feeding ourselves, therefore, treatment of HIV at a government facility would be most suitable� feels Shahjad Husain, a labourer.

Despite lack of knowledge about HIV, nearly 60 per cent workers reported that they were willing to work along with an HIV infected person, whereas about 19 per cent said that they would hesitate working with an HIV positive person.

5.4 Social Capital Nearly 93 per cent respondents have never received advice on matters of health or any other issues from any agency. Almost 78 per cent preferred to seek advice from their family and relatives. Only 3 per cent respondents thought it was OK to seek advice from an NGO. 64 per cent respondents feel they are important and valuable members of the society, 16 per cent feel they are not and an equal percentage of respondents don’t know whether they are important to the society or not. Only 5 per cent respondents are associated to any association or union.

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Participation in social and cultural activities was rather low, only 3 per cent workers had ever participated in such events.

5.5 Women’s Reproductive Health 44 per cent of the women in the sample did not consult a doctor or go for a medical check up at the time of pregnancy, while 32 per cent went for at least one medical check up during pregnancy. From among those who went for check ups, only 6 women were tested for HIV during pregnancy. Shyama, a migrant from Chattisgarh whose three children were all born at home, was of the opinion that “pregnancy and birthing were natural processes which could be managed well and comfortably by women in the household or community themselves. All this (pregnancy related issues) is being complicated by health professionals for their own monetary gains�.

40 per cent of he women respondents had up to 2 children, while 26 per cent had up to 4 children. Another 26 per cent women had no children at all. Apart from one woman who reported domestic violence, none of the women reported experiencing sexual harassment at work or domestic violence. Similarly only 1 woman reported having discussed issues related to HIV with her husband, and 2 women had spoken to their husbands about using condoms while having sex.

Only 7 per cent women were familiar with STIs, while only 3 of them reported that they had suffered from STIs, spoken to their husbands about it and underwent treatment for it.

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6. PROJECT INTERVENTION: COMPONENTS AND STRATEGIES Success in improving health depends on specific efforts to promote appropriate behaviours. Here, it is important to note that there are various levels of influence which the project utilized in order to impact the target population’s behaviour and health. The following levels of influence were identified to work with the migrant construction workers: Table 6.1 Levels of Influence Concept Individual factors Interpersonal factors

Institutional factors Community factors Public Policy factors

Definition Individual characteristics that influence behaviour such as knowledge, attitudes, beliefs and personality traits.

Interpersonal processes and primary groups including family friends and peers that provide social identity, support and role definition.

Rules, regulations, policies and informal structures that may constrain or promote recommended behaviours.

Social networks and norms or standards that exist formally or informally among individuals, groups and organizations.

National policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control and management.

6.1 Behaviour Change Communication

Figure 6.1 BCC through street play

The project aimed at improving the health seeking behaviour of the target community and reducing stigma and discrimination. For this, the needs/risk assessment survey helped to provide an understanding of the social, economic, ecological and psychological factors that render their vulnerability towards HIV and other illnesses. Certain strategies were outlined for generating awareness, which were aimed at creating a positive impact,

improving hygiene and sanitation, health seeking behaviour as well as health status of the workers. On the basis of data gathered in the needs assessment, the Outreach workers interacted with the target community, and volunteer peer 37

leaders were identified and trained. Volunteer peer leaders in turn educated, motivated and sensitised the target group through inter-personal communication.

This was done with the aim of ensuring sustainability for the Project’s efforts as the VPLs will remain within the community even after the project has graduated out. Awareness and sensitization workshops as well as community meetings were organized for labourers, contractors, site-supervisors, as well as managerial staff.

6.2 STI Care facilities Maitri had partnered with AHF India Cares to provide for testing and treatment facilities for the workers. All testing and treatment was voluntary. Through the ORWs and VPLs, the target community was educated and informed about the benefits of testing and treatment and the harms of not taking any health action if the symptoms of an ailment kept recurring. Maitri also partnered with the Integrated Counselling and Testing Centres (ICTC), B.K. Hospital, Faridabad in each intervention district so as to form referral networks to provide for treatment and care facilities of STIs and other opportunistic infections.

Two Health camps were organized at the construction sites and the health issues of men and women were addressed by professionally qualified medical practitioners (both male and female). Apart from this, a Resource Mapping of the construction sites and nearby areas was done. This led to identification of NGOs, medical and other services available in the Figure 6.2 The Health Camp area, and helped Maitri develop linkages with the service providers, and strengthen the referral services component. As a result of this, Maitri could develop links with Sai Dham Trust Clinic close to the site as well as The Red Cross Society of Faridabad.

6.3 Condom Promotion and distribution

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During the workshops, community meetings and oneto-one interactions, use of condoms was promoted and encouraged by the outreach workers as well as volunteer peer leaders.

Condom demonstrations were also done by outreach workers and peer educators.

Figure 6.3 Condom demonstration and distribution

Condoms were distributed among the target population and were also made available with the VPLs who the workers

could contact for condoms. Arrangements would be made to keep condom boxes at the dhabas, tea-stalls, pan-shops etc. where workers could access them. For this, dhaba owners were sensitized previously through outreach work, workshops and group discussions.

6.4 HIV/TB testing and treatment For providing testing and treatment facilities for HIV and opportunistic infections, Maitri had partnered with AHF India Cares. AHF has been providing testing and treatment to a large number of people living with HIV/AIDS, and bring with them the technical expertise to support the project. Partnership was also forged with the Revised National Tuberculosis Control Programme (RNTCP) for providing testing and treatment facilities for TB. Here, it is important to stress that any testing or treatment has been purely voluntary.

However, before introducing the testing and treatment, the target population was educated with regard to the benefits of testing and the harms of an untreated infection, whether TB or HIV. 6.5 Capacity Building With the strong belief that capacity building is an integral process to ensure efficacy of the interventions, utmost emphasis was laid on this. Capacity building in Sanjeevani was done at two Figure 6.4 HIV testing by trained Maitri staff 39

levels. At the first level the project staff was trained in various components of the project, since it has two important components, Research and Programme.

Care was taken to ensure that the staff recruited had the background and understanding required for project. Nevertheless, the staff, as a team, was oriented to the condition of migrant workers and their vulnerability to illnesses and HIV/STIs. They were familiarized with the needs of the project, the project plan and their scopes of work. The staff was also trained in the technical aspects of conducting research and outreach work.

Additionally, Capacity building of various stakeholders was a significant aspect of the intervention.

Sanjeevani is a custom made intervention for migrants in the construction industry.

6.6 Strategies The specific strategies adopted during the course of the project are as under:  







 

A baseline survey was conducted among the construction workers to gather demographic and health related information and to develop a research base.

A team of outreach workers generated awareness about general health and hygiene, HIV/AIDS, STIs and TB. They also worked at reducing stigma and discrimination within the target community. This was done by using appropriate mid media such as street theatre, IEC campaigns, audio/video/film shows, games, debates and discussions etc.

A pool of 20 volunteer peer leaders was developed to educate, motivate and sensitise the target group through inter-personal communication. This also done with the aim of providing sustainability to the efforts as the VPLs would remain within the community even after the project has graduated out.

While generating awareness about HIV and TB, the outreach workers and the volunteer peer leaders also informed them about the testing and treatment facilities and mobilize the community for voluntary testing and treatment. This led to improve their health status as well as their health seeking behaviour.

Testing and Treatment for HIV has been voluntary and has been facilitated

by Maitri. While the project field staff was trained in testing and counseling, in case of any sero-positive cases, AIDS Healthcare Foundation/India Cares was to provide treatment after receiving voluntary agreement from any individual. Fortunately, during the course of the project, no worker was tested positive.

Health camps were organized twice on the construction site.

A resource mapping of the site areas was done and partnerships with local organizations were forged to provide referral services to the target community.

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

The survey and interventions conducted at the construction site will be treated as a prototype. On the basis of the lessons learnt, any required modifications would be made and an intervention model would be developed which could be scaled up or replicated with other migrant populations.

6.7 Limitations and Constraints 

Sanjeevani was a project which can be defined as a ‘Complex Intervention in Complex Settings’. Migrants are a constantly fluctuating population. As a project focusing on HIV with BCC as a main component, it is important to be able to reach out to the target population over an extended period of time. However, some proportion of the population of migrants on the construction site was constantly in flux. In the process, some of the volunteer peer leaders who were identified and trained were also lost and additional VPLs had to be trained.



Maitri recognized that it does not have the technical expertise to provide for the testing and treatment needs of the workers on its own. However, this limitation led Maitri to forge partnerships with AIDS Healthcare Foundation India Cares and RNTCP; this provided not only the required technical expertise, but also an increased ownership to the project.



An intervention project with vulnerable populations aims at not only bringing about an increase in awareness, but also behaviour change, which requires a long term exposure and interaction with the target community. Project Sanjeevani was initially planned as a two year project with migrant construction workers. However, as a result of the economic recession, the project had to be concluded prematurely. In such a situation, assessing the impact of the interventions on a large number of variables, such as behaviour change, attitude change, health seeking behaviour etc. was a challenge.



During the time the project was being concluded, a large number of workers migrated out from the site in search of better remunerative alternatives. As a result, the sample size for the impact assessment study could not remain the same as the needs assessment survey. The sample size for the needs assessment survey was 323, while that for the impact assessment was 200.

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7. ASSESSING THE PROJECT IMPACT: THE RESULTS The term ‘migrant’ denotes a person living outside his or her native place. Many leave their homes because they do not have enough resources - fertile pastures and arable land, food, water, work or other fundamental requirements. The growing gap between rich and poor is the most significant driving force for migration. The enormous rate of population growth and the poor perspectives for economic development in some regions give rise to a tremendous migratory pressure.

Health Equity In the past 25 years, there has been extensive research conducted on health equity, and it is being brought to the forefront of social concerns. Typically, health equity research is concerned with one or more of the four sets of focal variables.

• Health outcomes • Health care utilization • Health subsidies • User fees /health care payments In the case of health, utilization, and subsidies, the concern is typically with inequality, or more precisely inequalities between the poor and the better-off. In the case of health care payments, the analysis tends to focus on ‘progressivity’ (how much larger payments are as a share of income for the poor than for the better-off), the incidence of ‘catastrophic payments’ (those that exceed a prespecified threshold), or the incidence of ‘impoverishing payments’ (those that cause a household to cross the poverty line) (Wagstaff & Lindelow, 2008).

Health is essential to wellbeing and to overcoming other effects of social disadvantage. Health Equity is an ethical principle that is considered an important goal in any health promotion programme. In Project Sanjeevani the interventions focused on strengthening the health seeking behaviour of the migrants. This was done through highlighting the importance of identifying symptoms, seeking medical help and enhancing their knowledge about availability of health care services.

When asked about what action was taken by the respondents when they fell ill, a large proportion of the respondents (86 per cent) reported consulting the doctor, whereas over 10 per cent said they treated themselves at home. Despite limited resources, fewer workers prefer to go to a government hospital for accessing healthcare services as it takes a whole day to wait in the queue to see the doctor.

It was also reported that the ‘doctors in the government hospitals do not have the time to listen to their problems’ and the medicines also have to be bought from the market. Nearly 60 per cent of workers preferred to go to the private practitioners, who ‘not only examined them well, but also gave them medicines’.

For this they were required to pay anywhere between Rs. 50 -100 per visit. The workers also reported consulting unqualified RMPs for interim relief when they 42

had lesser money in hand. Figure 7.1 below highlights the health seeking behaviour of the respondents with regard to their preference of where they seek treatment from.

Figure 7.1 Health Seeking Behaviour Table 7.1 presents comparative results of workers’ perceived health condition in the city as well as back home in their native place. During the baseline survey 48.6 percent workers felt that their health was better in the village as against 6.8 per cent who felt that their health was better in the city after migrating. During the impact assessment/endline survey it was found that 43.5 per cent of the workers felt their health was better in the village while 8 per cent workers felt that their health was better after migrating to the city.

Table 7.1 Comparison of health status in the migratory destination as well as native place Baseline Survey Health status better in native 157 (48.6) place Health status better at the 22 (6.8) migratory destination No difference in health 144 (44.6)

Endline Survey 87 (43.5) 16 (8.0) 97 (48.5)

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*Data in parentheses are percentages However, Ratilal from Katihar, Bihar felt that “food in the village is better; a lot of it is grown by us, our families and friends. It is just the good quality of food that keeps us healthy in the village. We never fell ill in the village. But, here I have visited the doctor so many times… sometimes for my wife, sometimes for my children, myself…” In contrast, Sukhram, a migrant from Jharkhand felt his and his family’s health was better after migration to the city. He was of the opinion that “we migrate for better resources, for a better life. Since we are earning more here, we can take good care of our health also”.

Health Promotion Health promotion refers to a collection of strategies that can be applied to many health and development issues. This means that these strategies must operate within the context of issues like 'empowerment', 'advocacy', 'communications', 'education', 'social mobilisation', 'community participation', These components of health promotion are not ends in themselves, but are means to achieve healthier and fuller lives. As a part of health promotion, Sanjeevani laid emphasis on the following components: Developing Personal Skills The awareness and knowledge of the target population about HIV was enhanced through sensitization and awareness workshops with workers as well as other stakeholders; community meetings were held with them and mid media like films and street theatre was used.

The following tables and graphs depict a significant difference between the respondents’ knowledge, behaviour and attitude about HIV during the needs assessment and impact assessment survey.

Strengthening Community Action The peer educators identified and trained during Sanjeevani were utilized as a resource within the community to increase the acceptance of the community and strengthen their knowledge and awareness.

Supportive Environments for health Creating an enabling or supportive environment is an essential component of interventions targeted at vulnerable populations. Health service provisioning was facilitated and referral networks developed.

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Knowledge and Awareness with regard to HIV The respondent’s HIV related knowledge before the interventions was very low.

Infact, nearly 54 per cent of them had never heard of HIV/AIDS. Consequently, awareness with regard to various modes of transmission and prevention was also very low. After the interventions, during the endline impact assessment study, it was found that almost 85 per cent of the workers knew what HIV/AIDS was, and their awareness about transmission and prevention of HIV had also increased drastically. Table 7.2 below depicts the significant difference in HIV knowledge and awareness of workers from baseline to endline surveys. Figure 7.2 also presents graphically the increase in knowledge and awareness levels of the workers.

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